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334                                          THE EAR

by paracentesis. (2) Increasing constitutional signs, e.g. fever and rising
pulse rate. (3) Copious pulsating discharge, rapidly refilling the meatus
after mopping out. (4) Sagging of the meatal wall, increasing oedema over
the mastoid process or zygoma. (5) Symptoms or signs of labyrinthine or
intracranial complication. (6) Onset of facial paralysis. (7) Persistent suppur-
ative otitis media for more than 2 weeks despite efficient treatment. (8) Pro-

gressive deafness.


This serious and treacherous condition associated with an unresolved or
latent otitis media is the result of inadequate treatment with antibiotics.
Failure to recognize the state of the infection and to apply vigorous treat-
ment may result in the development of an intracranial complication such as
meningitis or lateral sinus thrombosis. At the present time it occurs mostly
after the administration of oral penicillin given for too short a period of
time and, in some cases, in inadequate dosage, particularly at night-time.

DIAGNOSIS. Many cases are referred to hospital because of the persistence
of pain, deafness, fever and discharge or because of the appearance of an
intact unresolved reddish drumhead. Others are seen on account of recur-
rence of these symptoms after an apparent recovery. The persistence of
deafness is an important symptom. There may be mastoid tenderness and
headache with a slight rise hi temperature. The drumhead is usually con-
gested and full or thickened in appearance. Mastoid radiographs show
opacity or haziness with, in some cases, loss of cellular outlines on the
affected side.

TREATMENT. Admission to hospital for observation and adequate treat-
ment is necessary. Resumption of full antibiotic therapy is justifiable in the
absence of acute signs of mastoiditis, a watch being kept on the patient's
general condition, temperature chart, tympanic membrane, mastoid process
and hearing. In the absence of early signs of improvement and whenever
some doubt exists a cortical mastoidectomy is indicated, effective drainage
of the middle ear reducing the possibility of some permanent conductive


The steps of this operation are shown in Fig. 172. Its aim is to remove all
infected mastoid cells, and to this end each group of cells is systematically
explored and cleared so as to leave an appearance as in Fig. 173, B. Partic-
ular attention is paid to removing the reservoir of infection that tends to
accumulate in the tip cells, and to eradicate any spread of infection into the
petrosal cells between the middle fossa dura mater and the lateral (sigmoid)
sinus. The zygomatic cells are less frequently involved, but if there is clinical
evidence of such an extension they are opened. If the plates of bone over-
lying the dura mater and lateral sinus appear healthy they are not ppened
to expose these structures, but unhealthy bone in these situations must be
removed and the dura mater and sinus wall examined for extension of
disease. A swab of pus will be taken routinely for culture and sensitivity